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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT, <br /> Date 12-01-14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# `] 3 0 Q �_ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE S - <br /> PG&E (Ed Arroyo VALID - 14- (S TO 6- 1 -157 DRIVEWAYS: <br /> (Applicant Name) STREET _ 6wncls <br /> AREA QUAD <br /> 850 Stillwater Rd TYPE P __ <br /> (Mailing Address) FORMS <br /> NOTES <br /> West Sacramento, Ca 95605 <br /> (City,State,Zip Code) <br /> 916-760-1945 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> location 1 . Replace pole <br /> The crews will drill one hole on the N/E corner of Francis St at <br /> Belvedere Ave. <br /> 3 i ori �-1 - <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of _,by performing the following work(description of work): <br /> This location is not on the Hwv. <br /> Work will commence on or about 211L11/S for approximately. days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin Cwnty and subject to inspection and approval, <br /> 12-01-14 <br /> Signature of ARP cant-Title Date <br /> MLCF1JfRALSERVICES-ZLELGLFU"VWgtl.AST.RPSiEkaiCACHLE^ITPEWrTAPPUCATION.DOC (�n7) <br />